Telling Patients the Whole Truth

During a recent shift, I decided to call “a code,” which brings in the rapid response team. My patient’s heart was racing and his breathing had become intensely labored. Also he’d just moaned: “I’m gonna die in this bed.”

The team arrived and drew some blood. The patient’s left lower lung was gone and his right was filled with fluid, but his condition wasn’t as dire as it seemed. The intensive care doctor quickly returned with the lab results and stood close to the patient. He spoke in a loud, clear voice, making sure he would be heard over the hissing of the wall oxygen and the small crowd of people in the room. “Good news,” he said. “Your lab work just came back and everything looks good. You’re not going to die.”

Such a bald statement; no one ever yells out “die” in a hospital. But I was watching my patient and saw him relax after hearing that he was not going to die in his bed. Literally, he breathed easier.

It’s easy for doctors and nurses to be bold when the news is good; more difficult when it’s not. Recently I cared for a patient in her 60s. This woman had survived more relapses of her cancer and more rounds of chemotherapy than almost any other patient I knew.

Although she spent her days listening to gospel music and reading the Bible, she was also one of the meanest patients we ever had on the floor. She had thrown staff out of her room and cursed both nurses and doctors who frustrated her. Perhaps it was that combination of spirituality and cussedness that kept her alive, but the aggressiveness of her disease had finally overcome her, and our deep bag of medical tricks was empty.

I’d been her nurse off and on during her many hospitalizations. Now, at the end, a son and daughter who lived in the area had appeared. (None of us even knew she had children.) Whereas the mother was sharp-edged and aggressive, the daughter was soft-spoken and seemed to be making a tremendous effort to be kind.

While the patient slept, her daughter spoke resignedly about her mother being a “difficult” patient and admitted that she had struggled with her mother her entire life. And then she collected herself and gave me a sad smile. “Well,” she then said, “at least we got some good news about her disease yesterday.”

I looked at her, surprised. There was nothing about this patient’s condition that could be considered good news. I realized that the daughter must have misunderstood the results of a lab test that had come in the day before — or the meaning of the test had been poorly communicated. The test had shown that the patient’s bone marrow was free of the disease that had been killing her. That sounded like good news, except for the fact that the chemotherapy had destroyed the bone marrow entirely, which sometimes happens, and the marrow was empty of all cells, good and bad alike.

The daughter had the impression that the test results meant we had cured her mother’s cancer where it started, and technically, it wasn’t a lie. But that hope-inspiring statement came nowhere near the real truth. The woman’s disease had migrated to her central nervous system and to nodes on her spine. Her marrow was disease-free, but her body was not. And there was nothing more to be done for this patient in terms of curative care. She could not get more chemo until her marrow recovered, and without chemo, her disease would continue to spread, and she would die.

I thought about what to say. It is painful to give someone such undeniably bad news, but seeing the look of hopefulness on the daughter’s face I decided to speak up. I explained her mother’s condition.

“Oh,” she said, and her eyes opened wide. Then she slumped down, deflating into herself. Was it resignation she was feeling, or relief? Maybe a little of both. She nodded at me, and I told her I was sorry.

The patient was soon moved into hospice care, and a few weeks later she was dead.

Both patient experiences left me thinking about how we in the medical profession communicate with patients. It’s not easy to deliver or receive the news that you or someone you love has run out of options; that there is no hope. But people want the truth. In fact, they crave it.

It may be just as important to tell someone they are dying as to tell them that they aren’t. So much harder, but needed, and in the end, perhaps even more wanted and more kind.